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HomeMy WebLinkAboutCentral Coast Refrigeration - Insurance Certificate (2020)CENTCOA-44 MCHIESA ACOR CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/29/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License # OE02096 CONTACT Jeffrey Fisher DiBuduo & DeFendis Insurance Brokers, LLC PHONE FAx P.O. Box 5479 (A/C, No, Ext): (A/C, No):(831) 637-1226 Fresno, CA 93755-5479 E-MAIL SS:jfisher@dibu.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Security National Insurance Company 19879 INSURED INSURER B : Allmerica Financial Benefit Insurance Company 41840 Central Coast Refrigeration, LLC I INSURER C : PO Box 2314 I INSURER D : Hollister, CA 95024 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF ' POLICY EXP LIMITS LTR INSD WVD (MMIDD/YYYY) (MM/DDIYYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ICLAIMS -MADE F_X] OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO ❑ LOC JECT OTHER: B AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED _ AUTOS ONLY X AUTOS X HIRED X NON -OWNED AUTOS ONLY _ AUTOS ONLY X NA118763102 UMBRELLA LIAB OCCUR AB EXCESS LICLAIMS-MADE DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below AW FA89650903 04/08/2019 04/08/2020 DAMAGE TO RENTED 100,000 PREMISES (Ea occurrence) $ MED EXP (Anv one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ 04/08/2019 04/08/2020 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ EACH OCCURRENCE $ AGGREGATE $ PER STATUTE I EERH E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Gilroy Senior Center, 7371 Hanna St., Gilroy, CA 95020 Certificate Holder is named as Additional Insured as respects General Liability per form CG2010 07/04 to be issued by the Carrier. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Gilroy THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Y Y ACCORDANCE WITH THE POLICY PROVISIONS. Its officers, officials and employees 7351 Rosanna St. Gilroy, CA 95020 AUTHORIZED REPRESENTATIVE I AzzF25 ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Policy Number: NA118763102 Endorsement Effective: 5/29/201912:01 a.m. Named Insured Countersigned By: CENTRAL COAST REFRIGERATION LLC A4, SCHEDULE Name of Person or Organization: CITY OF GILROY, ITS OFFICERS, OFFICIALS AND EMPLOYEES 7351 ROSANNA STREET GILROY CA 95020 Location: 7371 HANNA STREET GILROY CA 95020 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II —Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to "bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. The words "you" and "your" refer to the Named Insured shown in the Declarations. D. "Your work" means work or operations performed by you or on your behalf; and materials, parts or equipment furnished in connection with such work or operations. 49-0108 0711 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 1 Used with permission Primary Wording If required by written contract or agreement: Such insurance as is afforded by this policy shall be primary insurance, and any insurance or self-insurance maintained by the above additional insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute to it. Waiver of Subrogation If required by written contract or agreement. We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of "your work" done under a contract with that person or organization. Page 2 of 2 0 ISO Properties, Inc., 2000 49-0108 0711 CENTCOA-44 MCHIESA CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �6--''"� 05/29/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License # OE02096 CONTACT Jeffrey Fisher DiBuduo & DeFendis Insurance Brokers, LLC PHONE FAx P.O. Box 5479 (A/C, No, Ext): (A/C, No):(831) 637-1226 Fresno, CA 93755-5479 I E-MAIL ADDRESS: jfisher@dibu.com I INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Security National Insurance Company 19879 INSURED INSURER B: Allmerica Financial Benefit Insurance Company41840 Central Coast Refrigeration, LLC INSURER C PO Box 2314 INSURER D Hollister, CA 95024 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER LTR INSD WVD POLICY EFF POLICY EXP (MM/DDNYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE FX OCCUR NA118763102 04/08/2019 04/08/2020 DAMAGETO 100,000 X S (RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ 5,000 _ PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY E LOC 2,000,000 JECT PRODUCTS - COMP/OP AGG $ OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO _ AWFA89650903 04/08/2019 04/08/2020 BODILY INJURY (Per person) $ OWNED SCHEDULED X AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ X AUTOS X AUUTOS ONLY accidentDAMAGE ONLY (Perr $ UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION PER I OERH AND EMPLOYERS' LIABILITY Y� ANY PROPRIETOR/PARTNER/EXECU I IVE E.L. EACH ACCIDENT $ FFICER/MEMBER EXCLUDED? N / A (O Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Gilroy Senior Center, 7371 Hanna St., Gilroy, CA 95020 Certificate Holder is named as Additional Insured as respects General Liability per form CG2010 07/04 to be issued by the Carrier. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Gilroy THE EXPIRATION DATE THEREOF; NOTICE WILL BE DELIVERED IN y y ACCORDANCE WITH THE POLICY PROVISIONS. Its officers, officials and employees 7351 Rosanna St. Gilroy, CA 95020 AUTHORIZED REPRESENTATIVE I Azo-:5 ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Policy Number: NA118763102 Endorsement Effective: 5/29/201912:01 a.m. Named Insured Countersigned By: CENTRAL COAST REFRIGERATION LLC SCHEDULE Name of Person or Organization: CITY OF GILROY, ITS OFFICERS, OFFICIALS AND EMPLOYEES 7351 ROSANNA STREET GILROY CA 95020 Location: 7371 HANNA STREET GILROY CA 95020 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II —Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to "bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. The words "you" and "your" refer to the Named Insured shown in the Declarations. D. "Your work" means work or operations performed by you or on your behalf; and materials, parts or equipment furnished in connection with such work or operations. 49-0108 0711 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 1 Used with permission Primary Wording If required by written contract or agreement: Such insurance as is afforded by this policy shall be primary insurance, and any insurance or self-insurance maintained by the above additional insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute to it. Waiver of Subrogation If required by written contract or agreement: We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of "your work" done under a contract with that person or organization. Page 2 of 2 0 ISO Properties, Inc., 2000 49-0108 0711 I' I' I I I, I I I I I I I I I I I IM-1 Phone: (831) 524-9770 PO Box 2314 Hollister, CA 95024 To: City of Gilroy From: Central Coast Refrigeration LLC 1-his is to state that Central Coast Refrigeration LLC is exempt from Workmans Comp insurance due to our Tecs being owners. We are an LLC run as a partnership. Hollv Forth 0 Office Admin Central Coast Refrigeration LLC Check A License - License Detail Page 1 of 2 Contractor's License Detail for License # 1028560 DISCLAIMER: A license status check provides information taken from the CSLB license database. Before relying on this information, you should be aware of the following limitations. CSLB complaint disclosure is restricted by law (B&P 7124.6) If this entity is subject to public complaint disclosure, a link for complaint disclosure will appear below. Click on the link or button to obtain complaint and/or legal action information. Per B&P 7071.17 , only construction related civil judgments reported to the CSLB are disclosed. Arbitrations are not listed unless the contractor fails to comply with the terms of the arbitration. Due to workload, there may be relevant information that has not yet been entered onto the Board's license database. Business Information CENTRAL COAST REFRIGERATION LLC P 0 BOX 2314 HOLLISTER, CA 95024 Business Phone Number:(831) 524-9770 This license is current and active. All information below should be reviewed. C38 - REFRIGERATION Entity Ltd Liability Issue Date 06/30/2017 Expire Date 06/30/2019 License Status Classifications Bondinq Information Contractor's Bond This license filed a Contractor's Bond with WESTERN SURETY COMPANY. Bond Number: 63173834 Bond Amount: $15,000 Effective Date: 04/24/2017 LLC EMPLOYEE/WORKER BOND This license filed a LLC Employee/Worker Bond with GREAT AMERICAN INSURANCE COMPANY. - Bond Number: 1771073 Bond Amount: $100,000 Effective Date: 04/24/2017 Bond of Qualifying Individual The qualifying individual JAROD RAY FORTH certified that he/she owns 10 percent or more of the voting stock/membership Effective of this company; therefore, the Bond of Qualifying Individual is not required. Effective Date: 06/30/2017 Workers' Compensation his license is exempt from having workers compensation insurance; they certified that they have no employees at this time. ffective Date: 06/30/2017 xpire Date: None Liabilitv Insurance Information https://www2.cslb.ca.gov/OnlineServices/ChecicLicenseIIlLicenseDetail.aspx?LicNum=1028560 5/31/2019 Check A License - License Detail Page 2 of 2 This license has liability insurance with SECURITY NATIONAL INSURANCE COMPANY Policy Number: NA11876310 Amount: $2,000,000 Effective Date: 04/08/2018 Expiration Date: 04/08/2020 Liability Insurance History Other Personnel listed on this license (current or disassociated) are listed on other licenses. https://www2.cslb.ca.gov/OnlineServices/CheckLicenseII/LicenseDetail.aspx?LicNum=1028560 5/31/2019